MEDICARE: DR. RAMAH J WAGNER D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	CH8955	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	96871	OTHER	FL	BLUE CROSS BLUE SHIELD FL

General Provider Information

NPI Number	:	1578690178
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RAMAH J WAGNER D.C.

Provider Business Mailing Address
First Line	:	2775 S BAY ST
Second Line	:
City	:	EUSTIS
State	:	FL
Zip	:	32726-6501
Country	:	US
Telephone Number	:	352-589-5443
Fax Number	:	352-589-5549

Provider Business Practice Location Address
First Line	:	2755 S BAY ST
Second Line	:	SUITE D
City	:	EUSTIS
State	:	FL
Zip	:	32726-6587
Country	:	US
Telephone Number	:	352-589-5443
Fax Number	:	352-589-5549

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	09/30/2013

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